Here we discuss the influence of flicker, blue light, “light”
in general, and EMF, as emanating from conventional and compact
fluorescence lamps on non-skin related pre-existing conditions.
The various conditions are discussed separately and the possible
influence of the physical factors is evaluated using the
criteria outlined in section 3.2.

Five percent of the total world population has single
seizures, and the annual incidence is 50 in 100.000 (WHO 2001).
About 5 in 100 of epileptic people have photosensitive
epilepsy (Epilepsy Action
2007). Photosensitive epilepsy is a form of epilepsy in which
seizures are triggered by visual stimuli that form patterns in
time or space, such as flashing lights, bold, regular patterns,
or regular moving patterns. Often persons with photosensitive
epilepsy have no history of seizures outside of those triggered
by visual stimuli.

The visual trigger for a seizure is generally cyclic, forming
a regular pattern in time or space. Flashing or flickering
lights or rapidly changing or alternating images are an example
of patterns in time that can trigger seizures (Harding et al.
2005). Epilepsy Action
(2007) states that fluorescent lights should normally not cause
a problem, except for faulty lamps, which may flicker at a lower
frequency. However, much
higher risks are connected with television and video
games.

While photosensitivity of epileptics is scientifically proven
(Steinkruger 1985, Wilkins et al. 1999, Wilkins et al. 2004), it
is not analyzed if the flicker
frequency range >
120 Hz causes seizures, as do
frequencies of 15 – 18 Hz
(Hughes 2008) and of 3 Hz (Harding et al. 2005). Although an old
study of flicker (50 and 100 Hz) from fluorescent lighting with
aging lamps did not suggest a hazard to photosensitive patients
(Binnie et al. 1979), a more recent study reports that flicker
from screens with 50 Hz repetition frequency causes discharges
in the investigated subjects, whereas 100 Hz screens appear to
be safe (Ricci et al. 1998).

Conclusion

Seizures are induced by flicker but can be accurately
correlated to the frequency
only for a small range (3 Hz, 15 – 18 Hz) [Evidence level A].
There is no scientific evidence that
fluorescent lamps
including CFL induce seizures [Evidence level E].

As defined on the website of the National Institute of
Neurological Disorders and Stroke,
migraine is an intense
pulsing or throbbing pain in one area of the head. It is often
accompanied by extreme sensitivity to light and sound, nausea,
and vomiting. Migraine is three times more common in women than
in men. Some individuals can predict the onset of a migraine
because it is preceded by an "aura," visual disturbances that
appear as flashing lights, zig-zag lines or a temporary loss of
vision. People with migraine tend to have recurring attacks
triggered by a lack of food or sleep, exposure to light, or
hormonal irregularities (only in women). Anxiety, stress, or
relaxation after stress can also be triggers. For many years,
scientists believed that migraines were linked to the dilation
and constriction of blood vessels in the head. Investigators now
believe that migraine is caused by inherited abnormalities in
genes that control the activities of certain
cell populations in the
brain (National Institute of Neurological Disorders and Stroke,
2008).

It is estimated that 14% of the adults in Europe have
migraine (Stovner et al.
2006). According to self-reported information, certain visual
patterns can reliably trigger a migraine attack, such as high
contrast striped patterns or flickering lights (Shepherd
2000).

Fluorescent lamps can
cause eye-strain and headache (Wilkins et al. 1991). Patients
with migraine show
somewhat lowered flicker fusion thresholds during migraine-free
periods (Kowacs et al. 2004). In addition,
photophobia, which is an
abnormal perceptual sensitivity to light experienced by most
patients with headache during and also between attacks, is
documented in many studies (Main et al. 2000).

People with migraine
claim to be particularly sensitive to blue light (European Lamp
Companies Federation).

Conclusion:

Migraine can be induced
by flicker in general (up to about 50 Hz) and patients are light
sensitive during and between attacks [Evidence level A].
Scientific support for aggravating symptoms by flicker from
fluorescent tubes was not found [Evidence level D]. There is
anecdotal evidence of problems with blue light [Evidence level
D].

Irlen-Meares is a
learning disability that manifests itself primarily as a
difficulty with reading and spelling which may be improved by
use of coloured lens or
overlays. The Irlen-Meares syndrome is also known as
Meares-Irlen syndrome and closely linked to Scotopic Syndrome.
There is no consensus reached within the scientific community
about its actual distinctiveness from other forms of
dyslexia. It is separate
and distinct from reading difficulties resulting from other
causes, such as non-neurological deficiency with vision or
hearing, or from inadequate reading instruction. Evidence also
suggests that dyslexia results from differences in how the brain
processes written and/or spoken language. Although dyslexia has
a neurological basis, it is not an intellectual
disability.

Dyslexia occurs at all
levels of intelligence and causes fatigue, headache and word-
scrambling, and is considered a learning disability. Dyslectics
show impaired flicker detection at 10 Hz (Evans et al. 1994) and
do not react uniformly to a flickering
stimulus (5, 10, 15, 20,
and 25 Hz) (Ridder et al. 1997).

Irlen-Meares is a
problem associated with the brain's ability to process visual
information. The scientific literature, however, states that due
to a deficit in the visual magnocellular pathway, impaired
sensitivity to both drifting and flickering gratings exist
(Ben-Yehudah et al. 2001), as well as to flickering or moving
visual stimuli (Cornelissen et al. 1998).

Self-reporting suggests that fluorescence lighting in contrast
to incandescent light
aggravate the symptoms of
dyslexia. Probably the
main problems are caused by UV radiation and blue light, emitted
by cool white tubes (Irlen method 2008).

Conclusion:

It is has been shown that dyslectics and
Irlen-Meares patients tend
to have difficulties detecting flicker. Therefore, flicker from
fluorescent tubes should not be a problem [Evidence level A].
There are self-reported indications that the condition is
aggravated by mainly UV and blue light [Evidence level D].

Ménière’s disease is a
disorder of the inner ear. Although the cause is unknown, it
probably results from an abnormality in the fluids of the inner
ear. Ménière’s disease is one of the most common causes of
dizziness originating in the inner ear. In most cases only one
ear is involved, but both ears are affected in about 15 percent
of patients.

The symptoms of
Ménière’s disease are
episodic rotational vertigo
(attacks of a spinning sensation), hearing loss, tinnitus (a
roaring, buzzing, or ringing sound in the ear), and a sensation
of fullness in the affected ear. Tinnitus and fullness of the
ear in Ménière’s disease may come and go with concomitant
changes in hearing, occur during or just before attacks, or be
constant. There may also be an intermittent hearing loss early
in the disease, especially in the low pitches, but a fixed
hearing loss involving tones of all pitches commonly develops in
time. Loud sounds may be uncomfortable and seem distorted in the
affected ear. From all the Ménière’s disease’s symptoms, vertigo
is usually the most troublesome. Vertigo may last for 20 minutes
to two hours or longer. During attacks, patients are usually
unable to perform activities normal to their work or home life.
Sleepiness may follow for several hours, and the off-balance
sensation may last for days. The symptoms of Ménière’s disease
may be only a minor nuisance, or can become disabling,
especially if the attacks of vertigo are severe, frequent, and
occur without warning (Ménière’s disease 2008). Increased
sensitivity to physical stimuli like flickering or fluorescent
lights during the attacks of Ménière’s disease (e.g. vertigo) is
self-reported (Vestibular Disorder Association 2005). A
recommendation for vertigo is to provide an alternative to
fluorescent lighting (Job Accommodation Network 2005).

Conclusion:

Light conditions are not associated with
Meniere’s disease.
However, the attacks may be aggravated by flicker [Evidence
level D].

3.5.1.5. HIV/AIDS

The Human immunodeficiency virus
(HIV) is a retrovirus that
kills the T-helper cells
which are essential components of the human body's immune
system. Therefore, HIV decreases the ability of the body to
fight infection and disease which usually leads to the
development of the so-called acquired immunodeficiency syndrome
(AIDS).

HIV-positive persons with
retinal damage (see the
Retina diseases section
below) have been shown in one study to have increased
sensitivity to flickering light (Plummer et al. 1998). Problems
with fluorescent tubes are not reported.

Conclusion:

No risk from flicker concerning other symptoms than retinal
diseases has been found for
HIV-positive persons
[Evidence level E].

3.5.1.6. Retinal diseases

Photochemical damage from blue light may induce several
harmful effects to the
retina mainly by the
production of singlet oxygen (Rózanowska et al. 1995, 1998).
Therefore filters are recommended to protect
lens and retina from blue
light (Ham 1983), if the antioxidant defence mechanisms and the
presence of melanin cannot protect against the damage (Sarna et
al. 2003). HIV-positive
patients may have retinal damage such as infectious
retinopathies and noninfectious complications, which makes them
more sensitive to blue light (Plummer et al. 1998).

Conclusion:

Blue light may be harmful to those with retinal diseases
[Evidence level B]. There is also some evidence that prolonged
exposure to blue light may reduce the colour sensitivity of the
intact retina [Evidence
level B].

3.5.1.7. Autism/Aspergers Syndrome

Autism is a
neuro-developmental disorder characterized by deficiencies in
social interactions and communication skills, as well as
repetitive and stereotyped patterns of behavior. Recent
epidemiological data show that autism is a frequent disorder,
observed in 1 child in 500. The cumulated prevalence of diseases
belonging to the spectrum of autism (autism, Aspergers syndrome)
and pervasive developmental disorders not otherwise specified,
has been estimated at 1/167 (Orphanet 2008).

The studies of Colman et al. (1976), which suggested that
repetitive behavior can be aggravated by the flickering nature
of fluorescent illumination, had interpretative problems and
could not be replicated (Turner 1999). However, a putative
relationship between
autism and
migraine is still
suggested by similarities between the two conditions, including
the presence of sensory over-stimulation (Casanova 2008). This
suggestion is however made without any further investigation
into the importance of flicker.

Conclusion:

There is no evidence showing negative effects of fluorescence
light on autistic behavior, however, an influence cannot be
excluded [Evidence level D].

Chronic fatigue syndrome
is one of several names given to a potentially debilitating
disorder characterized by profound fatigue which lasts for at
least six months. It has a prevalence that varies from 0.2% to
above 2% (Wyller 2007). According to the US Centers for Disease
Control and Prevention, persons with
chronic fatigue syndrome
most often function at a substantially lower level of activity
than they were capable of before the onset of illness. In
addition to these key defining characteristics, patients report
various nonspecific symptoms, including weakness, muscle pain,
impaired memory and/or mental concentration, insomnia, and
post-exertional fatigue lasting more than 24 hours. In some
cases, CFS can persist for years. The cause or causes of CFS
have not been identified and no specific diagnostic tests are
available (Centers for Disease Control and Prevention, 2008) A
number of illnesses have been described that have a similar
spectrum of symptoms to CFS. These include
fibromyalgia syndrome,
myalgic encephalomyelitis, neurasthenia, multiple chemical
sensitivities, and chronic mononucleosis.

According to self-reporting, about 52,500 people in the UK (=
21% of myalgic encephalomyelitis) have increased sensitivity to
light (Action for M. E. 2008). Patient studies have also
indicated excessive light sensitivity (Söderlund et al. 2000).
This is in contrast to other studies, where reduced sensitivity
towards sunny, dry, and long days compared to controls can be
found (García-Borreguero et al. 1998), and which suggested a
disturbance of the biological clock (Durlach et al.
2002).

Conclusion:

There is conflicting evidence regarding patient’s sensitivity
towards light. Symptoms may be aggravated by many factors,
including light conditions as stated by self-reporting [Evidence
level D]. There is no evidence for a link between
chronic fatigue syndrome
and fluorescent lighting [Evidence level E].

According to the National Institute of Arthritis and
Muscoloskeletal and Skin Diseases,
Fibromyalgia is a disorder
that causes muscle pain and fatigue (feeling tired). People with
fibromyalgia have “tender points” on the body. Tender points are
specific places on the neck, shoulders, back, hips, arms, and
legs. These points hurt when pressure is put on them. People
with fibromyalgia may also have other symptoms, such as: trouble
sleeping; morning stiffness; headaches; painful menstrual
periods; tingling or numbness in hands and feet; and problems
with thinking and memory (sometimes called “fibro fog”)
(National Institute of Arthritis and Muscoloskeletal and Skin
Diseases, 2007).

Conclusion:

Light conditions do not play a role in
fibromyalgia [Evidence
level A]. Problems with
fluorescent lamps are not
investigated but are very unlikely [Evidence level E].

Developmental dyspraxia
is a developmental (e.g. spastic) coordination disorder which is
a life-long condition that is more common in males than in
females; the exact proportion of people with the disorder is
unknown since the disorder is hard to detect. Current estimates
range from 5% - 20% with at least 2% being affected
severely.

Conclusion:

No evidence in the scientific literature is found regarding
any influence of light conditions on
dyspraxia [Evidence level
E].

Photophobia is eye
discomfort in bright light, which occurs in many diseases
including migraine (see
above). Photophobia is a symptom most often associated with
pathological eye conditions such as
cataracts, corneal damage,
burns, infections,
inflammation, injury,
retinal detachment, etc. People with lighter-coloured eyes and
albinism often suffer from photophobia. Since only general
studies about effects of light are found, it is concluded that
the main problem is the light intensity; irrespective of
modulation of other light parameters.

Conclusion:

Any effect of flicker, blue light and fluorescent tubes has
not been investigated, but cannot be ruled out [Evidence level
C].

With adequate blocking of
UVC and
UVB radiation, the CFL do
not pose a risk for inducing snow-blindness (sunburn on the
exposed surface of the eye ball). However, recent measurements
(see section 3.4.) show that some commercially available CFL
emit traces of UVC and significant amounts of UVB radiation,
which could conceivably cause snow- blindness if the lamp is in
close proximity to the eye for an extended period of time (the
eye is far more sensitive to UVC radiation than the skin).
However, preliminary measurements (personal communication De
Gruijl) showed that threshold limits are not easily exceeded.
Long-term exposure of the eye to UV radiation (wavelengths lower
than 320 nm) may contribute
to cataract formation
(opacity of the lens). With
overhead positioning of lamps this should not pose a significant
risk in comparison to sun exposure, but with UV emitting lamps
at eye level contributions may become important.

There are no indications that fluorescent tubes used in room
illumination cause either snow-blindness or
cataract.

An in-depth description of the characteristics and occurrence
of EMF, as well as the current view on possible health effects
after exposure to these EMF can be found in the SCENIHR Opinion:
Possible effects of
electromagnetic fields
(EMF) on human health (SCENIHR, 2007). The limit of exposure to
the general public from EMF is based on guidelines by the
International Committee on Non Ionising Radiation Protection
(ICNIRP, 1998). In short, the levels are
frequency dependent and set
to avoid acute harmful effects, which in the low frequency part
of the spectrum may lead to nerve excitation, and in the radio
frequency part of the spectrum
tissue heating.

There have been claims that the
electromagnetic fields
(EMF) emitted from CFL could cause symptoms among persons that
consider themselves sensitive to CFL. Furthermore, it has also
been reported that persons experiencing symptoms from mobile
phones are also “sensitive” to CFL. The subjective symptoms that
are mentioned include dermatological symptoms like reddening,
tingling and burning sensations, but also headache, fatigue,
dizziness, concentration difficulties and nausea. The question
is thus if these symptoms can be triggered by EMF, and if CFL
irradiate such EMF.

Those that attribute specific health problems like the ones
mentioned above to any kind of EMF are often termed
“electromagnetic hypersensitive” (WHO 2005). This refers to
exposure to extremely low
frequency (ELF)
electromagnetic fields, as
well as to fields of the high frequency kind. The former fields
are typically generated from power lines and from various
electric devices. Examples
of high frequency fields are the fields emitted from devices
used for mobile communication (mobile phones and their base
stations). These fields have frequency components that belong to
the so called radiofrequency part of the spectrum (RF
fields).

The symptoms that are attributed to ELF and to RF fields are
similar. Many patients also claim that both types of exposure
trigger their symptoms. The question whether there exists a real
correlation between exposure to EMF and the reported symptoms
has been studied in epidemiological studies as well as in
provocation studies. The former studies allow for finding
possible statistical connections between field exposure and
long-term, chronic effects,
whereas the provocation studies can reveal if there are any
immediate effects by a specific type of exposure. There are a
number of published provocation studies, mostly on ELF fields,
but also on RF fields to an extent. Recent extensive reviews of
these studies clearly show that there is no connection between
acute EMF exposure (ELF and RF) and perceived symptoms (WHO
2005, Seitz et al. 2004, Rubin et al. 2005, Röösli 2008).
However, these studies do not contribute knowledge regarding any
long- term effect. There are few studies with appropriate
methodology that address long-term effects of RF exposure and
symptoms, whereas a somewhat higher number of studies have
focused on ELF effects on symptoms. Most studies have not found
any correlation between exposure and symptoms. One RF study
related to base stations was performed by Hutter et al. (2006)
who found a connection between exposure to higher power
densities (1.3 mW/m2) and some, but not all, of the
investigated self-reported symptoms.

The literature on the kinds and strength of EMF that are
emitted from CFL is sparse. However, there are several kinds of
EMF found in the vicinity of these lamps. Like other devices
that are dependent on electricity for their functions, they emit
electric and
magnetic fields in the ELF
range (mainly 50 Hz in Europe). In addition, CFL, in contrast to
the incandescent light
bulbs, also emit in the high
frequency range (30-60
kHz). These frequencies
differ between different types of lamps. A Swiss study
(Bundesamt für Energie, 2004), is one of the few available
studies where correct measurements of CFL and their EMF have
been performed. In this work, eleven different energy saving
lamps were investigated and compared with two types of ordinary
incandescent light bulbs. All measured values were far below any
limits set by guidelines of international organizations like
ICNIRP.

The 50 Hz magnetic field
that was measured 30 cm from the lamps was in the nT range,
which is very low and comparable to the background fields in any
room without electric
appliances that are using strong electric currents. The high frequencymagnetic fields differed to
some extent between different types of lamps, but were still in
the nT range 30 cm from the source.

The 50 Hz electric field
was also measured and found to be somewhat higher in CFL than
from normal lamps, but lower than from other
electric appliances.
Finally, the high frequencyelectric fields (which are
not present from incandescent bulbs) are measurable but at very
low intensity.

Conclusion:

Although there is scarce literature in the area, it seems that
the electromagnetic fields
generated from CFL are not unique to these lamps, and also not
strong in comparison with EMF from any other devices. It has
never been conclusively and convincingly shown that there exist
any connections between EMF and the symptoms that are reported
by persons with so-called
electromagnetic hypersensitivity,
although their symptoms are real and in many cases very severe.
Thus, based on current scientific knowledge, there do not seem
to be any correlation between EMF from CFL, and symptoms and
disease states [Evidence level A].

3.5.1.14. Conclusions regarding non-skin pre-existing conditions

There are several self-reported statements about adverse
health effects of
fluorescent lamps, partly
based on subjective perception and psychological effects and
lacking scientific evidence. There is a need for additional
experimental and epidemiological studies before final
conclusions can be drawn regarding several of the conditions
that are mentioned in the mandate for this Opinion.

There is evidence showing that flicker can cause seizures in
patients with photosensitive
epilepsy [Evidence level
A], although there are no reported effects of CFL having such
effects [Evidence level E].

Migraine can be induced
by flicker [Evidence level A], but no evidence has been provided
that CFL do that [Evidence level E].

It cannot be excluded that
Photophobia is induced or
aggravated by different light conditions, but it is not even
mentioned in self-reports [Evidence level C].

People with Autism/Aspergers syndrome have reported problems
which they attributed to fluorescent lighting.

There is sufficient evidence [Evidence level A] that the
conditions of patients with Irlen- Meares syndrome are not
influenced by CFL. No reported effects [Evidence level E]
indicate that symptoms in patients with ME,
fibromyalgia,
dyspraxia, and
HIV would be aggravated by
CFL.

However, any possible health problems related to flicker and
UV/blue light emission are minimized, if CFL are equipped with
functional high-frequency
electronic ballasts, double envelopes and adequate
coating.